BS -Dental, vision, and dental + vision package application (2)

Blue Shield of California Blue Shield of California Life & Health Insurance Company Dental plan, vision plan, and dental + vision package application

This form is to be used by applicants applying for a Blue Shield dental plan, vision plan or IFP Specialty DuoSM dental + vision package. Please include first month’s dues/premiums to avoid return of application.

You are eligible for any Individual and Family Plan (IFP) dental plan, vision plan or the Specialty DuoSM dental + vision package if you are a California resident at the time of enrollment. If you had any Blue Shield IFP dental or vision plan cancelled for any reason (by yourself or by Blue Shield), you must wait six months from date of cancellation before reapplying.

Part 1 – Coverage, plan, and applicant information

New enrollmentPlan transferAdd dependent family member to existing coverage

Requested effective date (1st day of the month)

Date

Dental PPOSpecialty DuoSM (dental + vision) package

Ultimate Vision 15/25/120*Ultimate Vision 15/25/150*Specialty DuoSM (dental + vision) package

Part 2 - Primary Applicant Information

First name*

MI

Last name*

Applicant’s Social Security number/ Tax ID number*

Male:Famale

Date of birth (month/day/year)*

Date

YesNo

I agree that Blue Shield and its affiliated entities and agents may communicate with me about my account and various health and wellness programs available to me, and other promotional information that may benefit me and my dependents, including by phone or text to the numbers I have listed on this form, using an auto-dialer or artificial or prerecorded voice; standard data rates apply. Participation is voluntary and you can opt-out at any time. For more information visit blueshieldca.com/terms.*

YesNo

Applicant’s cell phone number*

Format: (000) 000-0000.

Applicant’s other phone number (optional)

Format: (000) 000-0000.

Applicant’s business phone number (optional)

Format: (000) 000-0000.

ElectronicPaper

Primary applicant's initials*

Applicant’s Email address (Required for electronic communications)*

example@example.com

Go paperless! Please watch for an email with a link which will allow you to register your account, customize your communication preferences, and access your digital ID card and benefit information.

Home address (NO P. O . b o x )*

Apt No.

City*

State*

ZIP code*

Billing address (if different from home address)

Apt No.

City

State

ZIP code

Mailing Address (if different from home address)

Street Address Line 2

CityState

ZIP code

SpouseDomestic Partner

MaleFemale

First Name

MI

Last Name

Applicant's Social Security number

Date of birth (month/day/year)

Date

YesNo

If no, where does the spouse/partner reside? (address, including ZIP code and state)

Part 3(b) – Child dependent applicant information

Date of Birth

Dependent children must be under age 26.

MaleFemale

Relationship

Son/Daughter

First name

MI

Last name

Applicant’s Social Security number/Tax ID number

YesNo

If no, where does the dependent reside? (address, including ZIP code and state)

Primary applicant's initials*

1. Application for coverage: I understand that Blue Shield has the right to decline my application forcoverage. I also understand that I must be residing in California in order to be eligible for enrollment inthis plan/package. I will notify Blue Shield upon any change regarding my eligibility for the dental plan,vision plan, or Specialty DuoSM dental + vision package. I also agree to provide information requestedby Blue Shield to verify my eligibility or continued eligibility for coverage, and understand that failure tocooperate could result in cancellation of coverage. If you use a broker to help facilitate your enrollment,their compensation is based on a percentage of your total monthly premium. This is paid by Blue Shield.Your monthly premium will be the same whether you choose to use a broker or not. In addition, your brokermay receive a bonus if certain sales thresholds are met.

2. First month’s dues/premiums: Blue Shield requires first month’s dues/premiums at the time of applicationsubmission. Find your estimated monthly dues/premiums by going to buyblueshieldca.com or contact youragent. Refer to Part 6 for payment options. Failure to submit full payment of dues/premiums will result in areturn of your application. Please note that processing of your payment does not constitute approval ofyour application with Blue Shield or Blue Shield Life. If you include a check, it will be destroyed.

3. Dues/premiums: Dues/premiums are to be paid in full by the due date. Coverage will be canceled forfailure to pay dues/premiums in a timely manner as set forth in the Evidence of Coverage and HealthService Agreement/Policy as allowed by law.

4. Effective date of coverage: If you qualify for coverage, Blue Shield will notify you of your effective dateof coverage. If Blue Shield cannot honor your requested effective date, or is unable to issue coveragebefore the requested date, coverage will begin as soon as possible. If additional dues/premiums areowed, payment must be received before coverage becomes effective. Any charges incurred for servicesreceived prior to your effective date or after cancellation or termination of coverage are not covered.

5. Acceptance of application: You understand that only Blue Shield can accept your application and issuecoverage for a plan or policy requested on this form. Your agent or broker cannot issue or enroll you incoverage or change any terms or conditions of coverage.

6. Parents/guardians: If you are the parent or legal guardian of an applicant who is a minor, please sign onbehalf of the applicant at the bottom of this Part. 4. As the parent or legal guardian, you are identifiedas the person who may make inquiries and act on behalf of the applicant regarding this coverage (asallowed by law). In addition, you are agreeing to assume all responsibility for dues/premiums paymentsand for following the terms and conditions for coverage. If you are not the parent of the applicant, pleaseattach court documents that appoint you as the guardian of this minor. Mark one of the following boxesand identify the individual authorized to act on behalf of the minor (applicant):

7. Authorization for spouse/domestic partner to make changes: If you are an applicant whose spouse/domestic partner is also applying for coverage, please specify if you authorize your spouse/domesticpartner to make changes to the contract/policy on your behalf. You may discontinue this authorization atany time by sending a written request to Blue Shield.

8. Authorization for your agent to provide/obtain information: By leaving this box blank you authorize yourinsurance agent, broker, or producer (referred to as “your agent”) to access all information on thisapplication. Check the box if you do not want to give your agent this authorization.

9. Process to authorize Blue Shield to release personal and health information to a third party: If you wouldlike to authorize your spouse, domestic partner, or a third party to access your personal health information,please complete the form titled Authorization for the Use or Disclosure of Health Information. To obtain thisform, go to blueshieldca.com/privacy or call (888) 256-3650

10. California law prohibits an HIV test from being required or used by health insurance companies as acondition of obtaining health insurance coverage.

11. Response to requested information: You agree to cooperate with Blue Shield (or Blue Shield Life, asapplicable) by providing, or by providing access to, documents and other information requested (such ascourt orders to provide dependent coverage, etc.) to corroborate information provided in this applicationfor coverage. You acknowledge and agree that failure or refusal to provide these documents or theinformation requested may be cause to deny this application or rescind or cancel your coverage.

12. Receiving materials and communications electronically versus print: You will receive required benefit plan and coverage-related materials and communications via email, at blueshieldca.com/policies, and/or by signing into the Blue Shield website blueshieldca.com, as applicable. Documents that are made available to you electronically include:

Blue Shield Identification (ID) cards
Statement of Benefits (SOB)
Evidence of Coverage and Health Service Agreement (EOC)/Policy You have the right to obtain printed, mailed materials at any time and at no expense to you. To receive printed materials in the mail, to opt out of email communications, or if you have questions, please call (888) 256-3650.

I have reviewed all responses pertaining to me in this application. I have read the summary of benefits and the terms and conditions of coverage and authorizations set forth above. With my own signature below, I represent that the information provided in this application is complete and accurate to the best of my knowledge, and I understand and agree to the terms and conditions of coverage and the authorizations I have provided. (Important: Each adult applicant must provide their own signature I understand that I must inform Blue Shield if anything changes or is different from what I listed on this application before my enrollment with Blue Shield begins.

Parent onlyLegal guardian onlyQualified medical child support order designeeMark this box if Blue Shield is to only make changes to the contract upon written request by the person identified above

YesNo

Primary applicant's initials*

12. Receiving materials and communications electronically versus print: You will receive required benefit plan and coverage-related materials and communications via email, at blueshieldca.com/policies, and/or by signing into the Blue Shield website blueshieldca.com, as applicable. Documents that are made available to you electronically include:
Blue Shield Identification (ID) cards
Statement of Benefits (SOB)
Evidence of Coverage and Health Service Agreement (EOC)/Policy You have the right to obtain printed, mailed materials at any time and at no expense to you. To receive printed materials in the mail, to opt out of email communications, or if you have questions, please call (888) 256-3650.

I have reviewed all responses pertaining to me in this application. I have read the summary of benefits and the terms and conditions of coverage and authorizations set forth above. With my own signature below, I represent that the information provided in this application is complete and accurate to the best of my knowledge, and I understand and agree to the terms and conditions of coverage and the authorizations I have provided. (Important: Each adult applicant must provide their own signature I understand that I must inform Blue Shield if anything changes or is different from what I listed on this application before my enrollment with Blue Shield begins.

Signature of applicant/parent or legal guardian*

Today’s date*

Date

Print name (and your relationship if applicant is a minor)*

Important: Return the application within 30 days of your date(s) and signature(s)

Primary applicant's initials*

Part 6 – Billing and payment information

Calculate estimated monthly dues/premiums

Go to buyblueshieldca.com to get your estimated dues/premiums or talk to your agent to get estimated dues/premiums.
First month’s dues/premiums is required at the time of application submission.
Blue Shield will issue final dues/premium before any effective date of coverage. If the final amount differs from the estimated dues/premium and additional amounts are owed, payment must be received before coverage will take effect.

Your first month’s dues/premium can be paid by submitting a check* or money order. *When you provide a check as payment, you authorize Blue Shield either to use information from your check to make a one-time electronic funds transfer from your account or to process the payment as a check transaction. When we use the information from your check to make an electronic funds transfer, funds will be withdrawn from your account as soon as the date we approve your application and you will not receive your check back from your financial institution.

I authorized Blue Shield to charge my health insurance premium from my card / bank account.

Your full name*

CheckingSavings

Name on Acct

Initial paymentMonthly auto payment

Bank Name

Bank Routing#

Bank Account#

Initial paymentMonthly auto payment

please upload your credit/debit card photo

CVV(3 digits number on back of card)

Billing address (if different from home address)

Signature*

Date*

Date

Blue Shield complies with applicable state and federal civil rights laws. We also offer language assistance services at no additional cost. View our nondiscrimination notice and language assistance notice: blueshieldca.com/notices. You can also call for language assistance services: (866) 346-7198 (TTY: 711) If you are unable to access the website above and would like to receive a copy of the nondiscrimination notice and language assistance notice, please call Customer Care at

Servicios de asistencia en idiomas y avisos de no discriminación

Blue Shield cumple con las leyes de derechos civiles federales y estatales aplicables. También, ofrecemos servicios de asistencia en idiomas sin costo adicional.

Vea nuestro aviso de no discriminación y nuestro aviso de asistencia en idiomas en blueshieldca.com/notices. Para obtener servicios de asistencia en idiomas, también puede llamar al (866) 346-7198 (TTY: 711).

Si no puede acceder al sitio web que aparece arriba y desea recibir una copia del aviso de no discriminación y del aviso de asistencia en idiomas, llame a Atención al Cliente al

如需檢視我司的非歧視通知和語言幫助通知，請造訪 blueshieldca.com/notices。您還可致電尋求語言協助服

Shield of California is an independent member of the Blue

Blue Shield of California Blue Shield of California Life & Health Insurance Company Dental plan, vision plan, and dental + vision package application

This form is to be used by applicants applying for a Blue Shield dental plan, vision plan or IFP Specialty DuoSM dental + vision package. Please include first month’s dues/premiums to avoid return of application.

Part 4 – Authorizations, terms, and conditionsPlease read the following terms and conditions carefully. Each applicant age 18 and older is required toreview the completed application and provide their own authorization and signature. Keep a copy of thisapplication for your records.

Part 6 – Billing and payment information

Nondiscrimination and Language Assistance Services

(888) 256-3650 (TTY: 711)